AMA Journal of Ethics®

Illuminating the art of medicine

An Argument for Patient Autonomy in Elective Surgery

A discussion of the ethics of performing anti-aging interventions for older patients.

Commentary by Michael Van Vliet, MD, and Joseph Rosen, MD

Florence is a zestful 73-year-old. In addition to spending a lot of time keeping up with her six grandchildren, she exercises most days. She recently won first place in the masters’ division of an Olympic distance triathlon, and is preparing for a 50-mile bike ride for charity. Since her husband passed away last summer, she has thrown herself into exercise, and it shows.

Despite having a very athletic body, particularly for her age, Florence is dissatisfied. Every time she looks in the mirror, instead of seeing toned muscles, she sees sagging breasts, facial wrinkles, drooping eyelids, and crows’ feet. She made an appointment with Dr. Doherty, a plastic and reconstructive surgeon.

Dr. Doherty was surprised at how fit this 73-year-old woman was. After talking about her triathlon success, Dr. Doherty asked, “What can I do for you?” Florence proceeded to explain that, despite all the exercising she does, she feels like “a wrinkled, saggy old prune.” She wants to feel as good on the outside as she does on the inside. She said that, after giving it a lot of thought, she wants a facial makeover—specifically, a rhytidectomy (face-lift) and blepharoplasty (surgery to remove sagging tissue or wrinkles around the eyelids)—and a breast lift. She is even contemplating having very modest breast implants put in. If she is going to have the breast lift surgery anyway, why not go from an A to a B cup?

Commentary

The ethical debate about the use of surgery to better the way one looks requires both critical reflection and interpretation of one’s values. The decision to operate can bring about suffering or damage to a patient, but it also has the potential to improve quality of life.

What each of us defines as happiness is subjective and personal. For some, physical appearance is a paramount contributor to happiness. Of course, not all that makes one happy in life is necessarily good. If the good that comes about from a choice outweighs any downsides, however, and the choice does not intentionally jeopardize the well-being of one’s self or others, then it is morally acceptable to strive for it.

Florence is a person for whom fitness and appearance are important. An energetic widow reinvigorated after her husband’s death, Florence achieves happiness through exercise, the feeling of youth, and good health. She deserves credit for her quest to retain the energy and health of her youth. A person’s physical well-being is intimately correlated with his or her mental well-being. Dr. Doherty has an opportunity to add to the good in Florence’s life. She explains that lifting her breasts and eliminating her facial wrinkling will make her feel even more youthful than she already does and will contribute to her overall well-being.

Aging is a natural, normal, and, some believe, beautiful process. Some see facial wrinkles as markings of experience, knowledge, and wisdom. A subset of these people also think that countering this natural process is unethical. Anti-aging interventions will certainly not contribute to the self-esteem or happiness of people with that belief. To others, however, aging is a source of distress. It makes them feel ugly and lethargic. To these people, anti-aging interventions contribute to self-satisfaction and overall mental well-being. Anti-aging interventions make them feel younger and more vivacious. If those in this group decide on surgical reversal of the aging process, having been adequately informed of the range of expected outcomes and the risks of the procedures, then it is ethical to operate on them.

Just as one’s reaction to the aging process is subjective and personal, every person ages at a different rate and to a different degree. Of course, there are similar trends that a plastic surgeon sees, namely ptosis, or sagging of skin. Patients commonly note drooping of the eyelids and the middle portion of the face. Jowls, laxity of the neck, and sagging of the breasts are also common, as are crow’s feet and wrinkles. Nevertheless, each and every person experiences these changes to a different degree and at a different rate.

Ultimately, when individuals identify conditions that contribute to their happiness and do not violate the rights of others or the morals of society in general, their right to seek those conditions is ethical. On the surgeon’s side, to be able to aid in that pursuit is to help the patient, but it requires a serious discussion of risks and benefits. As with any operation, the anticipated benefit must outweigh the risk posed by the operation in order to make proceeding ethical. Plastic surgery today is very safe, but it is not without risk. In this and every situation, Dr. Doherty must examine the whole patient and assess and inform her of her risk. Age should always be a factor, albeit a small one, in choosing one’s patients; comorbidities are more important. Of course, it is essential to explain to the patient the inherent risks of any operation, namely bleeding, infections, scarring, wound breakdown, and cardiovascular complications related to the anesthetic.

Once the patient accepts these low but real risks, it is critical that the surgeon be frank about what the patient can expect from the operation. The surgery can proceed if, and only if, the patient comprehends and accepts what the surgeon can deliver. Despite Florence’s age, if she is otherwise healthy and the surgery itself poses little risk to physical health, then the benefits to her are likely to outweigh the surgical risk.

The other consideration worthy of discussion in this case is the economic consequence of the surgeon’s actions. One may argue that plastic surgery is financially wasteful and that these health care dollars could be better spent. Yet the money for the operation is coming not from an insurance company but from Florence’s own bank account. There is no financial strain on society or on the government health care budget when one chooses to have cosmetic surgery, unless complications from surgery occur.

In summary, the question of whether or not it is ethical to perform plastic surgery in a given case depends on the particulars of that case. Age, alone, is not a sufficient reason to reject the request of a patient who is healthy, competent, and informed of the risks and benefits and who has autonomously decided that the surgery will contribute to his or her overall happiness.

Further Reading

MichaelVan Vliet, MD, is a 4th-year plastic surgery resident at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire. He received his MD from Albany Medical College and completed his training in general surgery at DHMC.

JosephRosen, MD, is an associate professor in the plastic surgery department at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire. He received his MD from Stanford School of Medicine, where he also completed his residency in general and plastic surgery. He is further trained in peripheral nerve surgery, hand surgery, and microsurgery.

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The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental.The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.